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Somatic symptom disorder

A somatic symptom disorder, formerly known as a somatoform disorder,[1][2][3] is any mental disorder which manifests as physical symptoms that suggest illness or injury, but which cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder (e.g., panic disorder).[4] Somatic symptom disorders, as a group, are included in a number of diagnostic schemes of mental illness, including the Diagnostic and Statistical Manual of Mental Disorders. (Before DSM-5 this disorder was split into somatization disorder and undifferentiated somatoform disorder.)

In people who have been diagnosed with a somatic symptom disorder, medical test results are either normal or do not explain the person's symptoms, and history and physical examination do not indicate the presence of a known medical condition that could cause them, though it is important to note that the DSM-5 cautions that this alone is not sufficient for diagnosis.[1] The patient must also be excessively worried about their symptoms, and this worry must be judged to be out of proportion to the severity of the physical complaints themselves.[5] A diagnosis of somatic symptom disorder requires that the subject have recurring somatic complaints for at least six months.[6]

Symptoms are sometimes similar to those of other illnesses and may last for years. Usually, the symptoms begin appearing during adolescence, and patients are diagnosed before the age of 30 years.[7] Symptoms may occur across cultures and gender.[6] Other common symptoms include anxiety and depression.[6] However, since anxiety and depression are also very common in persons with confirmed medical illnesses,[8] it remains possible that such symptoms are a consequence of the physical impairment, rather than a cause. Somatic symptom disorders are not the result of conscious malingering (fabricating or exaggerating symptoms for secondary motives) or factitious disorders (deliberately producing, feigning, or exaggerating symptoms).[9] Somatic symptom disorder is difficult to diagnose and treat. Some advocates of the diagnosis believe this is because proper diagnosis and treatment requires psychiatrists to work with neurologists on patients with this disorder.[6]

Contents

Somatic symptom disorders are a group of disorders, all of which fit the definition of physical symptoms similar to those observed in physical disease or injury for which there is no identifiable physical cause. As such, they are a diagnosis of exclusion. Somatic symptoms may be generalized in four major medical categories: neurological, cardiac, pain, and gastrointestinal somatic symptoms.[10]

Body dysmorphic disorder: wherein the afflicted individual is concerned with body image, and is manifested as excessive concern about and preoccupation with a perceived defect of their physical appearance.

Illness anxiety disorder: A somatic symptom disorder involving persistent and excessive worry about developing a serious illness. This disorder has recently gone under review and has been altered into three different classifications.[citation needed]

Abridged somatization disorder[15] – at least 4 unexplained somatic complaints in men and 6 in women

Multisomatoform disorder[6] – at least 3 unexplained somatic complaints from the PRIME-MD scale for at least 2 years of active symptoms

These disorders have been proposed because the recognized somatic symptom disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:[16]

Somatic symptom disorder has been a controversial diagnosis, since it was historically based primarily on negative criteria - that is, the absence of a medical explanation for the presenting physical complaints. Consequently, any person suffering from a poorly understood illness can potentially fulfill the criteria for this psychiatric diagnosis, even if they exhibit no psychiatric symptoms in the conventional sense.[17][18] In 2013-4, there were several widely publicized cases of individuals being involuntarily admitted to psychiatric wards on the basis of this diagnosis alone.[19][20] This has raised concerns about the consequences of potential misuse of this diagnostic category.

In the opinion of Allen Frances, chair of the DSM-IV task force, the DSM-5's somatic symptom disorder brings with it a risk of mislabeling a sizable proportion of the population as mentally ill. “Millions of people could be mislabeled, with the burden falling disproportionately on women, because they are more likely to be casually dismissed as ‘catastrophizers’ when presenting with physical symptoms.”[18]

Psychotherapy, more specifically, cognitive behavioral therapy (CBT), is the most widely used form of treatment for Somatic symptom disorder. In 2016, a randomized 12-week study suggested steady and significant improvement in health anxiety measures with cognitive behavioral therapy compared to the control group.[21]

Moreover, brief psychodynamic interpersonal psychotherapy (PIT) for patients with multisomatoform disorder has shown its long-term efficacy for improving the physical quality of life in patients with multiple, difficult-to-treat, medically unexplained symptoms.[23]

Antidepressant medication has also been used to treat some of the symptoms of depression and anxiety that are common among people who have somatic symptom disorder.[22] Medications will not cure somatic symptom disorder, but can help the treatment process when combined with CBT.